1. What every clinician should know

Vulvar pruritus is the most common symptom of skin disease. In evaluating vulvar pruritus, it is helpful to differentiate women with acute symptoms from those with chronic symptoms. Acute anogenital pruritus often is infectious, with allergic and irritant contact dermatitis playing a role in some cases. Genital infections such as trichomoniasis and cadidiasis as well as dermatitis should be considered in the differential. Chronic pruritus, in general, has a history of gradual onset, examples of which include lichen simplex chronicus as well as lichen scleroses, psoriasis and various manifestations of HPV-related disease.

The term dermatitis describes a poorly demarcated, erythematous and usually itchy rash. Subtypes are numerous and can be classified as either exogenous (irritant or allergic contact dermatitis) or endogenous (atopic or seborrheic dermatitis). Dermatitis has been reported to occur in 20-60% of women presenting with chronic vulvar symptoms, with atopic being by far the most frequently encountered. Irritant contact dermatitis has been identified in 5-26% of women with diagnosed vulvar dermatitis, often as a result of exposure to irritants such as detergents, soaps, perfumes, semen, and prophylene glycol, an additive found in many topical medications.

Vulvar lichen simplex chronicus is a chronic eczematous disease characterized by intense and unrelenting itching and scratching. Patients commonly reported sleep disturbances as a result of the itching. In vulvar specialty clinics, lichen simplex chronicus is frequently encountered. Commonly seen is middle and late adult life, it can also be seen in children. Nearly 65% to 75% of patients will report a history of atopic disease (hay fever, asthma, childhood eczema), and as such, lichen simplex chronicus can be seen as a localized variant of atopic dermatitis.

Lichen simplex chronicus represents an end-stage response to a wide variety of possible initiating processes, including dermatitis, candidiasis, as well as environmental factors such as heat, excessive sweating, irritation from clothing or topically applied products. In general, then, dermatitis and lichen simplex chronicus are essentially a continuum of the same disease process.

2. Diagnosis and differential diagnosis

Diagnosis

The diagnosis of dermatitis and lichen simplex chronicus begins with the history and physical examination. A careful and complete patient history is essential. The interview should start with having the patient define her symptom. Prompting with a variety of descriptors (itch, burn, rawness, pain, tingling, and irritation) may be useful. The patient who primarily reports symptoms other than itching may have a different underlying disorder. Burning and pain, however, can occur in patients with dermatitis and lichen simplex as a result of exposure to urine or other agents on areas of excoriations or erosions. The timing of the symptoms is therefore important. Identification of the onset of symptoms helps to identify the temporal development of the current condition.

Next, define the location of the pruritus (generalized, limited to a few areas or localized to the vulva). Identify triggers that make the pruritus better or worse (e.g., presence of vaginal discharge; relation to contraception, intercourse, menses; use of sanitary products). Obtain a list of prescribed, over the counter, and alternative therapies, as well as the length of use and results associated with each one. Inquiry about personal hygiene routines (douching, washing, types of detergents using for cleaning clothes). Identify preexisting conditions, such as history of HSV, zoster, diabetes, allergic rhinits, asthma, eczema, psoriasis.

Physical exam findings

In dermatitis, clinical signs can range from mild erythema, swelling and scaling to marked erythema, fissures, erosions and ulcers. Lichen simplex chronicus appears as one or more erythematous, scaling, lichenified plaques. Various degrees of excoriation can seen in both dermatitis and lichen simplex chronicus. In long-standing lichen simplex chronicus, the skin appears thickened and leathery, and areas of hyperpigmentation and/or hypopigmentation may be present. Erosions and ulcers also can develop, most commonly from chronic scratching.

Other testing

Confirmation of the diagnosis in patients suspected to have dermatitis or lichen simplex chronicus should include assessment to rule out candidiasis. Vaginal fungal cultures can be helpful in this regard. Vulvar biopsy results are nonspecific in the setting of dermatitis and of little use in the evaluation. For lichen simplex chronicus, biopsy (which will reveal marked hyperkeratosis with widening and deepening of the rete ridges) can be helpful if underlying disease is suspected (e.g., lichen sclerosus) or treatment fails.

Finally, the clinical appearance of the vulva does not always help confirm the diagnosis, and in many cases, more than one process has led to the symptoms the patient reports. It is not unusual to encounter a mixed picture where endogenous dermatitis or another epithelial disorder has been worsened by use of creams or ointments to which the patient has had an adverse reaction (see photo).

Other infections and skin disorders can mimic the appearance of dermatitis and lichen simplex chronicus. Infections such as vulvovaginal candidiasis, trichomonas, bacterial vaginosis, herpes, and dermatophytes should be considered in the differential of vulvar pruritus. Lichen sclerosus, tinea cruris, lichen planus, and psoriasis are also in the differential. Appropriate utilization of office (vaginal pH, saline and KOH preparations), laboratory (STI testing, culture, serologies) and pathologic testing should be carried out. In difficult cases, referral to a specialist in vulvar disorders may be helpful.

3. Management

For contact dermatitis and lichen simplex chronicus, the first line of therapy includes several steps, outlined below.

Removal of the offending agent or practice

Routine vulvar care should include washing the vulva with warm water only, avoidance of washcloths, gentle patting the vulva dry, use of pericare bottles to rinse the vulva, avoidance of douching, avoidance of perfumes or deodorants on the vulva, use of fragrance and dye-free detergents for washing of clothes and bedding, use of cotton underwear.

Correction of barrier function

Sitz baths

Treatment of concomitant infection if present

Application of thin layer of plain petrolatum

Estrogen therapy if indicated

Elimination of scratching and rubbing

For nocturnal itching, consider use of low-dose tricyclic medications such as doxepin and amitriptyline which induce sleep and sedate for a longer period of time than diphenhydramine or hydoxyzine (these sedate but produce REM sleep during which patients will still rub). SSRIs are useful during the day to avoid drowsiness

Reduction of inflammation

Dermatitis

A mid- to high-potency corticosteroid ointment should be used for two to three weeks. A weaker corticosteroid (e.g., 1% hydrocortisone) can be continued as needed. In recalcitrant cases, oral or intramuscular corticosteroids may be necessary.

Lichen simplex chronicus

Recommendations range from mid-potency to high-potency corticosteroid ointments. Application begins daily, with reduction to every other day once symptoms are approximately 50% improved. Most patients experience full resolution within four to six weeks, at which point therapy can be discontinued. For failures, second line therapy with the topical calcineurin inhibitors can be considered in patients who fail or cannot tolerate therapy (recall: FDA black-boxed these medications due to increased risk of malignancy in animal models and recommended they be considered second line therapy only). In difficult cases, oral or intramuscular corticosteriods may be needed.

Weekly fluconazole is often recommended to prevent candidaisis in women exposed to high-potency topical steroids.

4. Complications

In general, treatment will result in clinical care. Left untreated, patients suffer from chronic itching. Depression and anxiety may result. As noted above, patients exposed to high-potency corticosteroids are at risk for the development of secondary infections, both bacterial and fungal, as well as a possible allergy to the treatment itself. Patients started on therapy should therefore be advised to return if symptoms worsen on therapy. Exposure to topical steroids also places patients at risk for atrophy and striae formation, for example.

5. Prognosis and outcome

Treatment should result in clinical care. Patients remain at risk for repeat episodes of dermatitis and should be counseled to seek care early if symptoms develop in the future.

6. What is the evidence for specific management and treatment recommendations